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California's health insurance exchange will use the threat of exclusion from its approved provider networks as a way to motivate hospitals and doctors to reduce the number of medically unnecessary Cesarean sections.

Beginning in 2019, insurance companies that contract with Covered California must either exclude from their networks any hospitals that don’t meet the federal government’s 2020 target C-section rate or explain why they aren't, according to the new contract approved by the exchange's board last week.

An insurer that wants to keep an underperforming hospital in its network will have to provide Covered California with "the rationale for continued contracting" and document "efforts the hospital is undertaking to improve its performance," the contract states.

When complications arise during pregnancies, C-sections can save the lives of mothers and infants. But experts say in far too many instances, women undergo C-sections when the procedure is not medically indicated.

Attention is focused on how often doctors perform C-sections on first-time moms with low-risk pregnancies, defined as those that have reached the 37th week or later and consisting of one fetus in the head-down position.

The federal government has set a goal of reducing C-sections in these low-risk situations to 23.9 percent by 2020. The national rate was 26.9 percent in 2013, according to the Centers for Disease Control and Prevention.

Many California hospitals are far from the 23.9 percent target: Statewide, 10 percent of hospitals had rates of 33 percent or higher in 2014, according to recent data from the California Hospital Assessment and Reporting Task Force.

Leah Binder, president and CEO of the Leapfrog Group, a national nonprofit focused on health care quality and safety, lauds Covered California’s new policy.

"Covered California is a national leader on quality of care," Binder says. "I don't know of any other state this advanced in demanding better maternity care for its residents."

Covered California's contract also requires insurers to alter their payment structure by 2019 so there is no financial incentive to perform a C-section rather than deliver a baby vaginally.

The California Hospital Association strongly supports Covered California’s goal of reducing medically unnecessary C-sections, says spokeswoman Jan Emerson-Shea. But, she points out, doctors and their patients also play a role in this effort, so "it is important that payment provisions apply to OB-GYN physicians as well as hospitals."

The Maternal Quality Care Collaborative's Main says he would support physicians being held accountable if they are part of larger medical groups that contract with the exchange.

For its part, the California Association of Health Plans will "remain engaged" as Covered California works out the details of its new C-section policy, says spokeswoman Nicole Evans.